The jaw-dropping spectacle in which their party holds the White House and majorities in both houses of Congress and yet failed on its first, and arguably most significant, agenda item should disabuse Republicans of a number their deeply held, inaccurate beliefs:
Running a business is good experience for running government. We saw just how different the business and government worlds can be. President Trump’s fame and skill at self-promotion don’t necessarily work to promote policies. Especially if you have made your wealth in a closely held business with no accountability, no vast bureaucracy and no stakeholders (aside from family members), you may not have developed the organizational skills and powers of persuasion needed to forge legislative compromise. You have to lead and cajole, not threaten, lawmakers. Trump cannot fire — or even bully — Freedom Caucus members as he could competitors or suppliers in the business world. Trump does not understand how to wield presidential power or motivate his own party; he’s a one-man band who now has to conduct a symphony orchestra where details, coordination and timing are critical. Trump’s high-handed style (Take the vote!) and unwillingness to get bogged down for more than a couple of weeks in a difficult project were detrimental.
Presidents can hire advisers to get the details right. Sorry, but the president has to know something. Trump’s glaring unfamiliarity with the issues and distaste for policy made him wholly ineffective in addressing the substantive concerns of lawmakers. A purely transactional approach in which nothing matters but the deal turns out to be useless when trying to enact policies, as opposed to trying to get voters to pick you over another candidate. As an amateur in politics with no intellectual curiosity, Trump had no policy knowledge himself nor even an idea of the sorts of people he would need and what skills could be valuable for them to have. He admires only billionaires and generals who “look the part,” but he needs grizzled political pros who live and breathe politics. He mistakenly chose cronies who made him feel comfortable but who could not devise a plan that reflected his campaign message. (Reince Priebus and Stephen K. Bannon have never drafted a simple bill, let alone constructed a redesign of the health-care system.) Trump outsourced his most important legislative initiative, didn’t bother to understand the conflicts within the GOP, didn’t have the staff to explain what he needed to do and therefore was left with ineffective buzzwords and trite phrases that fell on deaf ears.
You don’t need to be a policy wonk to govern. Trump is so used to creating his own reality, denying facts and projecting his own ill-founded beliefs onto others (Everyone hates Obamacare!) that he could not understand why lawmakers would object to whatever he put in front of them. In dealing either with highly ideological members (demanding minimalist government involvement in healthcare) or pragmatic moderates (who could not sell constituents on rollbacks in benefits), he did not recognize the issues that stood in the way of a deal, let alone know how to resolve them. As for the people who were supposed to be the wonks (Tom Price and Paul Ryan) they greatly exaggerated the imminent demise of Obamacare and failed to appreciate that people will keep a flawed system rather than throw caution to the wind on a plan whose purpose is to provide less security in the name of free markets.
Conservative dogma from the 1980s translates directly into a program for governing. For more than seven years Republicans have told themselves the public hates Obamacare because it “limits freedom” or because it contains too many taxes (the lion’s share applicable only to the very rich). In fact, what upsets people is Obamacare’s failure to make good on its promise to lower premiums and deductibles. Polls consistently showed that the percentage of those who liked Obamacare or wanted it to be more generous dwarfed the percentage of those who wanted to scrap it. There is not a large constituency for minimalist federal government, no matter how fervently the speaker of the House pines for defederalized Medicaid. The public wants Obamacare to work better and deliver more coverage with lower out-of-pocket costs. That may be entirely unrealistic, but that’s where the voters were coming from. Republicans have badly misread the public’s attitude toward government and toward health care specifically. In fact, President Barack Obama did move the goalposts, and Americans now think government should help guarantee coverage for just about everyone.
We can return to a free market for health care. Even before Obamacare we did not have a free market for health-care insurance. In a free market, a provider doesn’t have to give away service if you cannot pay up. That is not how the health-care system works. Hospital emergency rooms have not had the ability to turn people away for roughly 30 years. (“Very simply, prior to the implementation of the Emergency Medical Treatment and Active Labor Act of 1986, a patient coming into a hospital emergency department often had no right to treatment or even evaluation, no matter how dire his or her condition. If patients could not prove that they had the resources to pay for care, they could be turned away or sent elsewhere—sometimes in a taxi, sometimes on foot. They often suffered adverse health consequences as a result of delayed care. And sometimes they died.”) Unless we want to do away with that guarantee of treatment — plus Medicaid and Medicare — and to be prepared to price those with preexisting conditions or chronic conditions out of health insurance you will not have anything approaching a free market. Figuring out how market forces and enlightened self-interest (shopping for value) can be harnessed to help contain costs is the challenge going forward, not pretending we can treat health care like another commodity.
Obamacare cannot be fixed. Saying this over and over again does not make it true. At the very least, it is possible to try to make it better. Rules on going in and out of the health-care exchanges can be toughened to keep young and healthy people in the pool of insureds. Insurance companies can be incentivized to return to the exchanges. Medicaid expansion can be applied nationwide in exchange for lenient waivers that let states experiment with different ways to provide services to the poor. Changing the formula to determine the amount of subsidies may be helpful. More support for rural health care where providers are scarce may be needed. Some of these may work and some may not. But having refused to try anything, Republicans are in a poor position to declare the situation hopeless. And if in defiance of GOP predictions that Obamacare will “explode” or go into a death spiral, Obamacare continues providing coverage for 12 million or so Americans in the exchanges Republicans will once again be discredited as anti-government hysterics.